Healthcare Provider Details

I. General information

NPI: 1790824332
Provider Name (Legal Business Name): ROBERT BRUCE WORTH MD INC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 01/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 ANDERSON DR SUITE 203
ABERDEEN WA
98520-1055
US

IV. Provider business mailing address

1020 ANDERSON DR SUITE 203
ABERDEEN WA
98520-1055
US

V. Phone/Fax

Practice location:
  • Phone: 360-533-6063
  • Fax: 360-533-2204
Mailing address:
  • Phone: 360-533-6063
  • Fax: 360-533-2204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberMD00018292
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00018292
License Number StateWA

VIII. Authorized Official

Name: JAN DAHL
Title or Position: OFFICE MANAGER
Credential:
Phone: 360-533-6063